COMPLIANCE INFO_2013-2017 - Laserfiche WebLink

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AQUiN SAN .JOAQUIN COUNTY e �{ *ENVIRONMENTAL HEALTH DEPARTMEN MI 1868 East Hazelton Avenue, Stockton, CA 95205-6232 P.. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si oq v_ora/ehd A�1Fo • it • ' I'M• .1 1j !� • , . • Facility Name: Inspection Date: ❑ ❑ mechanical Model: Facility Address: THIS.FACILITY IS SUBJECT TO iiniii-11,11111Aii �. 1 Service R quest #: ❑ Leak detector ❑ Onsite Service Technician's ame:ICC Service-Technician/installer Exp. Date: Manufacturer Training: /`{ -- ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: THIS.FACILITY IS SUBJECT TO iiniii-11,11111Aii �. 1 ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other THIS.FACILITY IS SUBJECT TO iiniii-11,11111Aii �. 1 Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 20 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection Other: see below • ...:• is • - •- EHD 23- / Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT ' f �. PITMAN THIS.FACILITY IS SUBJECT TO iiniii-11,11111Aii �. 1 �Iff . rl1 %lid. �VIA 111 11111 ;. � EHD 23- / Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT